What is the treatment for chronic ischemic stroke?

Treatment for Chronic Ischemic Stroke

For patients with chronic ischemic stroke (beyond the acute phase), long-term antiplatelet therapy is the cornerstone of secondary prevention, with clopidogrel 75 mg daily or aspirin 75-100 mg daily plus extended-release dipyridamole 200 mg twice daily as preferred first-line options over aspirin monotherapy. 1, 2

Long-Term Antiplatelet Therapy (Primary Treatment)

The American College of Chest Physicians recommends single antiplatelet therapy for noncardioembolic ischemic stroke with the following options (Grade 1A): 1

• Clopidogrel 75 mg once daily (preferred over aspirin, Grade 2B) 1, 2, 3
• Aspirin 75-100 mg once daily plus extended-release dipyridamole 200 mg twice daily (preferred over aspirin, Grade 2B) 1, 2, 3
• Aspirin 75-100 mg once daily (acceptable alternative) 1, 2
• Cilostazol 100 mg twice daily (Grade 2C evidence) 1, 2

Important: Long-term dual antiplatelet therapy (aspirin plus clopidogrel) beyond 21-30 days is NOT recommended, as it increases bleeding risk without additional benefit (Grade 1B). 1, 3

Cardioembolic Stroke (Atrial Fibrillation)

For patients with ischemic stroke and atrial fibrillation, oral anticoagulation is strongly recommended over antiplatelet therapy (Grade 1A-1B): 1, 2, 3, 4

• Direct oral anticoagulants (DOACs) are preferred over warfarin for nonvalvular atrial fibrillation 3, 4
• Warfarin (INR 2.0-3.0) is an alternative if DOACs are contraindicated 3, 4
• Oral anticoagulation is superior to aspirin alone or combination aspirin plus clopidogrel (Grade 1B) 1, 2
• Anticoagulation should generally be initiated within 1-2 weeks after stroke onset 4

Critical caveat: Dabigatran is contraindicated in patients with severe renal impairment (creatinine clearance ≤30 mL/min). 2

Special Stroke Subtypes

Embolic Stroke of Undetermined Source (ESUS)

• Antiplatelet therapy is recommended, NOT oral anticoagulants 1, 2, 3
• Follow the same long-term antiplatelet regimen as noncardioembolic stroke 3

Extracranial Artery Dissection

• Either antiplatelet therapy or oral anticoagulants for at least 3 months 1

Carotid Web

• Antiplatelet therapy is recommended 1

Fibromuscular Dysplasia

• Antiplatelet therapy plus lifestyle modification 1

Sickle Cell Disease

• Chronic blood transfusions to reduce hemoglobin S to <30% of total hemoglobin 1

Risk Factor Management (Essential Components)

Aggressive management of vascular risk factors is critical for secondary prevention: 1, 4

• Blood pressure control: Aggressive long-term monitoring and treatment 1
• Lipid management: Statin therapy for dyslipidemia 4, 5
• Diabetes control: Optimization of type 2 diabetes management 5
• Lifestyle interventions: Diet modification, exercise, smoking cessation, alcohol moderation 5

Rehabilitation and Chronic Sequelae Management

Stroke patients should receive coordinated interdisciplinary rehabilitation: 1

• Assessment by rehabilitation professionals (physicians, nurses, physiotherapists, occupational therapists, speech-language therapists, social workers, dieticians) 1
• Person-centered, collaborative goal setting with regular review 1
• Task-specific therapy to optimize recovery 1
• Management of common poststroke problems: mobility impairment, balance deficits, cognitive dysfunction, dysphagia, depression, chronic pain 5
• Patient and family education provided formally and informally 1

VTE Prophylaxis (If Immobilized)

For patients with restricted mobility: 1, 4

• Prophylactic-dose LMWH is preferred over unfractionated heparin (Grade 2B) 1, 4
• Intermittent pneumatic compression devices are an alternative (Grade 2B) 1, 4
• Elastic compression stockings are NOT recommended (Grade 2B) 1

Critical Pitfalls to Avoid

• Do not use aspirin doses >325 mg daily long-term - side effects increase without additional benefit; 75-100 mg daily is as effective 3
• Do not continue dual antiplatelet therapy beyond 21-30 days in noncardioembolic stroke - increases bleeding without benefit 1, 3
• Do not use antiplatelet therapy instead of anticoagulation in atrial fibrillation-related stroke 1, 2, 3
• Avoid omeprazole and esomeprazole in patients taking clopidogrel - they reduce clopidogrel's antiplatelet activity; use alternative PPIs if needed 6
• Do not use oral anticoagulants in ESUS - antiplatelet therapy is the correct choice 1, 2, 3